What is "SWIM" breast reconstruction?

For so many women, the process of undergoing a mastectomy is truly life-altering, and the loss of their breasts can negatively impact their self-esteem. One option to help these women regain their confidence is undergoing breast reconstruction to help rebuild missing or damaged tissue and replace lost volume. This can be achieved through a variety of methods, but some of the most popular options include reconstruction with an implant or tissue transfer.

Skin-sparing wise-pattern internal mammary perforator breast reconstruction, also known as SWIM breast reconstruction, is a lesser-known option to repair the breasts after mastectomy. It is gaining popularity due to the natural-looking results that can be achieved. This procedure focuses on maximizing the shape and appearance of the breast by using excess fat and skin adjacent to the breast tissue to reshape the mastectomy site. Also known as a "Goldilocks mastectomy," this procedure is performed in one surgery, rather than as two separate surgeries with a mastectomy followed by breast reconstruction.

To learn more about how SWIM breast reconstruction is performed and the results that can be expected from a successful procedure, we reached out to ASPS Member Surgeon Kelly Killeen, MD.

ASPS: What exactly is SWIM breast reconstruction, and how does it differ from other types of breast reconstruction procedures?

Dr. Killeen: A SWIM flap is a type of breast reconstruction where we rearrange the tissue left on your chest after mastectomy to create a small breast.

ASPS: Who is the ideal candidate for SWIM breast reconstruction? Are there specific medical conditions or lifestyle factors that determine whether a patient is suitable for this approach?

Dr. Killeen: The ideal candidate for this procedure is a patient with large, droopy breasts who would like a small, perky breast after surgery while avoiding implants. In general, the only patients who are not candidates are those with scars on the breast, which may alter blood supply to the tissue, or medical problems that may cause issues with perfusion (blood delivery) to the tissue.

ASPS: How does SWIM breast reconstruction integrate with a mastectomy procedure? Is it performed immediately after the mastectomy, or does it require a separate recovery phase?

Dr. Killeen: The SWIM flap procedure is done at the same time as the mastectomy. It does not require a separate surgery and does not change the recovery period from mastectomy, significantly.

ASPS: Can you describe the types of results that patients can expect from SWIM breast reconstruction? How natural do the reconstructed breasts look compared to natural tissue?

Dr. Killeen: When comparing SWIM flaps to a free flap procedure like a DIEP flap or a natural breast, the reconstructed breasts are smaller and tend to be less projected. The SWIM procedure is less invasive and has a less intensive recovery compared to a free flap.

ASPS: What are the key steps in the SWIM reconstruction process? Could you walk us through the surgery from start to finish?

Dr. Killeen: The SWIM procedure begins with incisions in an anchor pattern. The lower portion of the breast is de-epithelialized, meaning the outer portion of the skin is removed, which allows this tissue to be placed inside. The lower portion of the breast tissue is then rearranged internally to create a breast mound. The upper portion of the skin is then pulled over this tissue, and a new nipple areolar complex opening is made. The skin is then closed with multiple layers of stitches.

ASPS: SWIM breast reconstruction often uses implant-based techniques. Can you explain the choice of implants used and how they are placed?

Dr. Killeen: SWIM flap reconstruction is a technique that does not utilize implants. You can use the tissue similarly to perform a breast lift at the time of implant-based reconstruction. With this method, the lower portion of skin that is de-epithelialized can be used to support the implant, which can sometimes allow for avoiding surgical scaffolding. This form of reconstruction is typically called an autoderm flap. Implants can be placed either under or over the pectoralis major muscle when using this technique.

ASPS: Are there any specific advantages of performing SWIM breast reconstruction in a single stage as opposed to traditional multi-stage procedures?

Dr. Killeen: SWIM flap is a wonderful option for women with larger breasts who would prefer a reduction and to avoid the use of implants. It is important to note that, as with all breast reconstruction techniques, revision surgeries are common to achieve the best possible result. This is true for SWIM flap reconstruction as well.

ASPS: Are there any limitations or challenges to using SWIM for breast reconstruction that patients should be aware of before deciding on this option?

Dr. Killeen: The main limitation is the amount of natural tissue the patient has left after mastectomy and the shape of the chest wall. We have less ability to control the size of the reconstructed breast as opposed to a free flap or implant-based reconstruction.

ASPS: What kind of recovery timeline can patients expect after undergoing SWIM breast reconstruction? Does it vary depending on factors like implant placement or patient health?

Dr. Killeen: Recovery for this type of reconstruction is similar to mastectomy alone. The main difference is that there tends to be more wound healing issues and a need for wound care after. Most patients are driving and back to work by 10 to 14 days. Full activity by one month.

ASPS: Are there any special considerations or additional procedures that might be needed to enhance the results of SWIM breast reconstruction, such as nipple reconstruction?

Dr. Killeen: SWIM flap is a procedure that preserves the nipple, so there is no need for nipple areolar reconstruction. If you are not happy with your size, you have the option of fat transfer, usually done three to four months after the mastectomy, in order to increase the size and shape of your reconstructed breasts.

ASPS: How do the results of SWIM breast reconstruction hold up over time? Are there any long-term issues or complications patients should be aware of?

Dr. Killeen: SWIM flaps are a procedure that holds up nicely with time. As the breasts created are small, dropping is uncommon. The main concern is scarring issues, and it is so important to have good follow-up with your surgeon to ensure proper healing.

ASPS: Can patients undergo additional surgeries or modifications to further refine their reconstructed breasts after SWIM reconstruction?

Dr. Killeen: Yes! Fat transfer is an option for patients who would like to increase their size and adjust the shape of their reconstructed breasts. Fat transfer can be done more than once in patients wanting even more of a size increase and the avoidance of implants.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.